Pneumatic Compression Therapy Part 2

Vascular Compression

The first part of this series dealt with pneumatic compression for the management of lymphedema and discussed the fact that there are three distinct modes of pneumatic compression; (lymphatic, venous and arterial). It explained that the purpose of this series is to educate nurses and other caregivers about these various systems since they are not well known or well understood in the general health care professional community. This lack of understanding can cause confusion which results in a delay in providing the patient with the appropriate therapy, particularly when the prescribing physician scribbles a vague order such as “compression booties”, leaving the nurse to try to decipher what is meant.

SYSTEMS FOR PREVENTION OF DVT

TED Hosiery

Any patient, who is unable to ambulate or is confined to bed for three days or more for any reason, should have DVT prevention applied. For patients at high risk for DVT, the TED hose is usually the first modality that comes to mind since it is the least expensive, however it is also the least effective. TED hose (short for Thrombo Embolic Deterrent), are usually full leg length elastic stockings which provide calibrated, graduated compression to the leg in an effort to prevent DVT. They are also available in knee-high versions and are usually open at the toes. The TED are a good plan of care for a younger individual who is expected to bounce out of bed after a few days and get back to ambulating, but in the case of a patient who is at high risk for DVT, such as an elderly nursing home resident, they often do not do the job.

Intermittent Vascular Compression

Unlike lymphatic systems, vascular systems produce compression via a rapid inflate/deflate cycle, occasionally referred to as a pulsatile cycle. This is designed to force blood up through the deep veins of the legs, thus preventing blood pooling in the lower extremities and helping to prevent the concomitant clotting which precedes a thrombo embolic event. Most intermittent vascular compression systems are available with a variety of leg sleeves in a choice of sizes which fit most patients. Some intermittent vascular compression devices are also available with foot boots which can be invaluable in very large bariatric cases where even the largest size leg sleeves do not fit the patient. Foot boots are also a good solution in cases where there are venous stasis ulcers or other types of wounds present on the lower legs, which may become painful if compressed.

Sequential Vascular Compression

As with intermittent compression, sequential vascular compression systems produce compression via a rapid inflate/deflate cycle, also occasionally referred to as a pulsatile cycle. The difference is this modality utilizes sleeves with a number of chambers, usually three or four. These chambers inflate from distal to proximal, assuring a more thorough and effective forcing of the blood up through the deep veins of the legs. Choice of intermittent or sequential compression should be at the discretion of the prescribing physician but is often left to the nurse or care giver.

Vascular Compression, Never Events and CMS Payment Issues

In the March, 2009 issue of JAMA, an article appeared discussing issues related to the fact that in August 2008, the US Centers for Medicare & Medicaid Services (CMS) added deep venous thrombosis and pulmonary embolism after total knee arthroplasty (TKA) and total hip arthroplasty (THA) to the list of never events. Covered was the issue that, A. ... if a patient experiences deep venous thrombosis or pulmonary embolism following one of these procedures, a portion of the payment made by CMS to hospitals is to be withheld. On the surface this decision seems to be a win win for hospitals, clinicians, and patients. Venous thrombo embolism (VTE) is a common cause of preventable harm, yet many hospitalized patients fail to receive adequate VTE prophylaxis. Accordingly, the strategy of using financial incentives to encourage better performance should result in fewer thrombotic events and consequently less morbidity and mortality related to VTE and its treatment. For many healthcare professionals, the prophylaxis of choice in this matter is pneumatic vascular compression. For the Long Term Care facility patients returning for recuperation from TKA and THA procedures, they should receive the same prophylaxis insofar as the potential for DVT continues. This period of time can be an indefinite period for some, but should be until the patient is able to ambulate for reasonable distances around the facility on a daily basis.

CHRONIC VENOUS INSUFFICIENCY AND VASCULAR COMPRESSION

Diagnostic signs of CVI:

Firm Edema

Dilated Superficial Veins

Dry thin skin

Hyperpigmentation

Lipodermatosclerosis

Atrophie Blanche

Venous dermatitis

Ankle flare

Ulcer characteristic location

When the diagnostic signs of CVI are first noted, prophylaxis to prevent CVI disease, which can include lymphedema and leg ulcers, should be initiated. These prophylactic measures are usually the same as for actual management of the disease, and include:

Avoid standing for long periods

Plantar flexion/Dorsiflexion

Exercise/weight loss

Good skin hygiene

Healthy, balanced diet

Quit smoking

Avoid restrictive clothing such as tight girdles or belts

Compression stockings

Intermittent pneumatic vascular leg compression

Unfortunately, pneumatic vascular leg compression is often overlooked, even though it is considered by many as the most effective means of prophylaxis and management of CVI. It supports the calf pump in the leg, which in elderly or otherwise infirm patients, has become weakened and cannot produce the required deep vein pressure required to move blood up through the deep veins of the leg. Careful evaluation by competent, trained personnel is required to determine if pneumatic compression is indicated; however, if it is indicated, it can mean the difference between disease prevention and disease management.

Additional information about all forms of pneumatic compression therapy can be obtained from Vascular PRN at 800-886-4331 or at www.VascularPRN.com.

Guest Article by Greg Gambor co-owner of Vascular PRN, a company which supplies pneumatic compression therapy equipment to nursing homes, hospitals, surgery centers and other medical institutions throughout the United States.

Greg Grambor is a graduate of Ramapo College of New Jersey, with a degree in communications. After serving as a medic and radio operator with the US 38th Air Defense Artillery in Song Hwan, Korea, from 1968 to 1970, Grambor spent almost 20 years in medical/industrial advertising on New York’s Madison Avenue. For eight of those years he was owner of an award winning medical/industrial advertising agency, Schachter, Grambor & Associates, Inc. This company worked on the introduction of the Pfizer ACTA Scanner, one of the world’s first commercially successful CAT scanners, and they also introduced the Elscint CAT scanner from Elscint Corporation of Israel to the American medical market, as well as the Varta Aviation Battery line of Germany to the American aviation market.

The company rounded out its stable of clients to include a hypodermic syringe manufacturer, a urologicals manufacturer and others. After moving to Florida in 1989 seeking a warm climate, Greg and his wife Diane owned a series of DME companies in the fields of oxygen, respiratory, polysomnography and diabetic testing supplies. The couple currently own and operate Vascular PRNK, a company which supplies pneumatic compression therapy equipment to nursing homes, hospitals, surgery centers and other medical institutions throughout the United States.The company is currently a National Distributor for ArjoHuntleigh Compression Therapy Equipment.